Adhesions and chronic pelvic pain (CPP)

How do adhesions cause chronic pelvic pain (CPP)?

Many women are held captive by a recurring or constant pain in the abdomen. The pain can be intense and sometimes debilitating. It may last for months or even years, leading some women to jump from physician to physician in search of a cure. 

Chronic pelvic pain is defined as a pain in the pelvic or lower abdomen area, not related to the menstrual cycle, which persists for six months or more. Because of its vague and inconsistent symptoms, chronic pelvic pain is difficult to diagnose. But it is real, and in most cases it can be treated. 

There may be one factor causing the pain or there may be many. If the pain is gynecological, it could be caused by such conditions as pelvic adhesions, endometriosis, or pelvic inflammatory disease. 

Adhesions are believed to cause pelvic pain by tethering down organs and tissues, causing traction (pulling) of nerves. Nerve endings may become entrapped within a developing adhesion. If the bowel becomes obstructed, distention will cause pain. 

Some patients in whom chronic pelvic pain has lasted more than six months may develop "Chronic Pelvic Pain Syndrome.” In addition to the chronic pain, emotional and behavioral changes appear due to the duration of the pain and its associated stress. 

According to the International Pelvic Pain Society:

"We have all been taught from infancy to avoid pain. However, when pain is persistent and there seems to be no remedy, it creates tremendous tension. Most of us think of pain as being a symptom of tissue injury. However, in chronic pelvic pain almost always the tissue injury has ceased but the pain continues. This leads to a very important distinction between chronic pelvic pain and episodes of other pain that we might experience during our life: usually pain is a symptom, but in chronic pelvic pain, pain becomes the disease." 

Chronic pelvic pain is estimated to affect nearly 15% of women between 18 and 50 (Mathias et al., 1996). 

Other estimates arrive at between 200,000 and 2 million women in the United States (Paul, 1998). 

The economic effects are also quite staggering. In a survey of households, Mathias et al. (1996) estimated that direct medical costs for outpatient visits for chronic pelvic pain for the U.S. population of women aged 18-50 years are $881.5 million per year. Among 548 employed respondents, 15% reported time lost from paid work and 45% reported reduced work productivity. 

Not all ADHESIONS cause pain, and not all pain is caused by ADHESIONS.

Not all surgeons, particularly general surgeons, agree that adhesions cause pain. 

Part of the problem seems to be that it is not easy to observe ADHESIONS non invasively, for example with MRI or CT scans. 

However, several studies do describe the relationship between pain and adhesions. 

According to an early study (Rosenthal et al., 1984) of patients reporting CPP, about 40% have adhesions only, and another 17% have endometriosis (with or without adhesions). 

Kresch et al., (1984) also studied 100 women and found ADHESIONS in 38% of the cases and endometriosis in another 32%. 

Overall estimates (Howard, 1993) of the percentage of patients with CPP and ADHESIONS is about 25%, with endometriosis accounting for another 28%. These figures must be understood in their context. 

It is important to recognize that emotional stress contributes greatly to the patients perception of pain and her/his ability to deal with the pain. 

Rosenthal et al. (1984) found that of the patients in whom a possible physical cause of pain (including ADHESIONS) could be identified, 75% had evidence of psychological influences on the pain. 

Because pelvic pain can be caused by a myriad of disorders, it is important to find a doctor who is sensitive to your needs and willing to take the time to solve the problem. Don't let anyone dismiss it as being " all in your head.". The solution may require time and energy, but most causes of pelvic pain can be treated successfully."